House Issues Report on 737 Max Cost, Consequences, Lessons

Report highlights the poor communication between Boeing and its stakeholders.

On March 8, 2017, the FAA granted Boeing an amended type certificate for the 737 Max 8, the 12th derivative of the 737 and the first successor aircraft to the 737 NG series. The first fatal crash of a Lion Air 737 Max 8 occurred just 17 months later near Jakarta, Indonesia. Another Max 8, this one operated by Ethiopian Airlines, crashed in March 2019 shortly after takeoff from Addis Ababa, Ethiopia. The 737 Max fleet was grounded shortly after the Ethiopian Airlines accident and remains grounded to this day. A key contributing factor in both accidents was Boeing’s new software system called the Maneuvering Characteristics Augmentation System (MCAS).

Last week, the Democratic Staff of the House Committee on Transportation and Infrastructure’s subcommittee on aviation, published a preliminary investigative report into the 737 Max following a year-long investigation. The committee’s preliminary findings, “The Boeing 737 MAX Aircraft: Costs, Consequences, and Lessons from its Design, Development, and Certification,” focus on five main areas; production pressures on Boeing employees that jeopardized aviation safety; Boeing’s faulty assumptions about critical technologies, most notably regarding MCAS; Boeing’s concealment of crucial information from the FAA, its customers, and pilots; inherent conflicts of interest among authorized representatives, or ARs, who are Boeing employees authorized to perform certification work on behalf of the FAA, and Boeing’s influence over the FAA’s oversight that resulted in FAA management rejecting safety concerns raised by the agency’s own technical experts at the behest of Boeing.

Within the preliminary findings, the committee identified five central themes. One theme explained the FAA failed in its oversight responsibilities to protect the public, citing a number of instances in which Boeing’s ARs did not raise issues about MCAS for fear it would interfere with the company’s goal to require no additional training of flight crews. In another, Boeing received FAA approval to “not install on the 737 MAX an Engine Indicating and Crew Alerting System (EICAS)—a system common in newly type-certificated aircraft since 1982 that displays aircraft system faults and failures and helps pilots prioritize responding to multiple or simultaneous indications. The FAA accepted Boeing’s argument about the impracticality and the economic expense of installing EICAS on the 737 MAX.”

Boeing did not classify MCAS as a safety critical system on the Max and also failed to inform pilots of its existence. Surprisingly, “in 2012, Boeing developed initial concepts for an MCAS annunciator to inform pilots when the MCAS failed, but never implemented it.” Boeing intentionally concealed information from the FAA, its customers and pilots about inoperable angle of attack disagree alerts installed on most of the 737 MAX fleet, despite their functioning being “mandatory” on all 737 MAX aircraft. The FAA also failed to hold Boeing accountable for these actions.

The report noted that “Boeing’s own analysis showed that if pilots took more than 10 seconds to identify and respond to a “stabilizer runaway” condition caused by an uncommanded MCAS activation, the result could be catastrophic. The Committee has found no evidence that Boeing shared this information with the FAA, customers, or 737 MAX pilots.” Finally the committee’s report said both Boeing and the FAA gambled with people’s lives after the Lion Air accident by not grounding the Max at that time. “In the days after the Lion Air crash, both Boeing and the FAA issued advisories for 737 MAX pilots that failed to mention the existence of MCAS, by name, on the aircraft.”

As part of its ongoing investigation, the committee held five public hearings with more than a dozen witnesses; obtained hundreds of thousands of pages of documents from Boeing, the FAA, and others involved in the aircraft’s design; heard from numerous whistleblowers who contacted the committee directly; and interviewed dozens of former and current employees of both Boeing and the FAA.

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